GW1--03456_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORI)
T 101111 can he used for single or Onalliple,wellsPot lurenrgl Use ONLY:
I.Well Contractor Information:
Mitchell Dean Cook
TFW
'A'cll Contractor Nam, ROM
7/ ft-2043 A ft. 3 71
ft. ft.
NC Well Coalractor Certification Number
P --ro.
- WkKNESS� MtAT ERIAL
Dennis Holland Well Drilling, Inc. R Tn
Company Name
kit".
2.Well Constructlo FROM u Perulrit#: To IF.I EK alLICKNES§
List all applicable wellpe, ................. ft. MATERIAL
permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well rise): ft. in.
'76
DIAN KR SU. TSIZF, IlllC "a
(JAgri ell I(it ral ft.
l.'JMu1licipaVI'ublic
00eOtherinal(1IC3tillg/COOIiO8 Supply) CJ Residential Water Supply(single)
KW
0111d"stri8l/Corninercial ".,.3.--P; �i:-,l
Supply(shared) 7 R0V7
(:4Re,sidential Water
_ FROM TO
171rli�utiD❑ _MATERI 1, EMPLACFMENTM
Non-Water Supply Oil
pply Well: IF t. f
CJnblonitorirlg CJRecovety ft.
Injection-well:
[.]Aquifer Recharge OGroundwater I Rrmcdiation 9*.......... -.,. . .
ClAquifer Storage and Rccovory 118albdty Barrier EMFLACFM
0 A q ui for Test 08tormwatcr Onainage
C)F.-,'xl)eriinetital'rechjiology OSubsidence CoIltl*ol ft.
"
C](.[cot 11 crina I(Closed Loop) Tmcu T, Li an h4fiddi _aifs,ec C-llnel;
Geo—thermal Hearin Conlin Rctum --(:)Other(explain'urder 421 Remarks)J ft. ft.
4.Date Well(s)Completed:0S. Well IDfl IV.A -
So.Well Location:
ft, ft.
ZVI 1A WA F f 8-2023
-
1`11vilitY/0%vner Name Facility lDff(ifaPplicable)
/0 zmz Lz , ft.
Physical Address,City, ft. ft.
and ZiP
County Pfirccl Identification No.(PFN)
5b.Latitude and Longitude In degrees/minutes/secouds or decimal degrees:
01'"'cli field,One[at/long is sufficient) 22,('ertificatioll;
3 N W
Signative of Certified Wol Contractor Date
6.Is(are)the well(s):101rermauent or l7Tcmporary
Ry signing this form,I hereby rertify thal the well(v)was(wrrc)ronso ucted in accordan(x
with 15A NCACO2C.0100 or 15A NC11C 02C.0200 Well Construction Standards and that o
7.Is this a repair to an existing well: GYes or VIN-0- copy ol'this record has been provided to the well owner.
If this is a repair,fill out hnoma well construction illformalion and explain the nature.ol'thr
repair faider#21 remarks section of on the back qf thisform. 23.Site diagragi or additional well details:
8.Number YOU May list',the back Of this page to provide additional wall site details or well
Of wells constructed: consliAlction details. You may also attach additional pages if necessary.
For nuiltiple injection or non-,valer supply it,clis ONLY with-die scone construction.you can
submit uneforni.. i
SUI)MI'll-rAl.IFINSTUCTIONS
9.Total well depth below land suffice:--ZOO-T 24a. For Ali Wells: Submit this lbri n within 30 days of completion of well
Fortnutuple Ivellslisr alldepths if(Iffferruit(exaniple-3@200'and 2@100') construction to tile rollowilig:
10.StRIIC water level below top of casing:­ 7e (ft.) Division of Water Resources,'J[Dforrnat!DO Processing Unit,
if—ter level is above casing,use".F 1617 Mail Service Cente1r,Ralei h,NC.1 27699-1617
11,Borehole diameter: (in.) 24b, For, 1pj_ecti(?u Wcfls ONLY: In addition ddition to sending the form to the address in
Rotary 24a abovt:, also submit a copy of this 11min within 30 days of completion of well
12.Well construction method;
(i.e.11119m.,rotary,cable,direct push,-T, construction to tile following:
Division of Water-Resources,Underground Injection Control Program,
70R W'ATPk SUPPLY WEIVS ONLY: 1636 Mail Service Center,Raleigh,NC27699-1036
Air lift 24 v,Eqi:Watcr Supply&Injection Wells:
On.Yield(urn) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type; H & H
Amount: 12 oz. well I Construction to tile, County health department of the count where
constrilotud.
North Carolina Dapaminont ofl-Envirovincia and Natural Resources--Division of Water Resources: Revised Augusi 201.3

-.--.-..-.................... . .. ........- ........-.
4Z[-1q73
�A .m Macon County NEW WELL CONSTRUCTION
ova Public Health CONSTRUCTION AUTHORIZATION
PRIVATE DRINKING WATER WELL
APPLICANTIOWNER HM Squared .-.--'�-- --._—_---- • 060622-P • 020123-
0AE
2
' ' Shared Well Residential —!— — T ' 7540583057 2.62
MNT—
LOCATION1073 Hicks Road
BMW
Left onto Mirror Lake Rd. right onto Hicks Rd,,property on rightIust_past 1029.— _
Permit Conditions .
Well shall be constructed in compliance with all NCAC 2C Rules. o
Maintain minimum setbacks as applicable.
Previous attempted well was dry, log # 111221-P.
New AOWE Septic Permit Log # 020123-AE.
Ensure Well is 100 feet from the septic tank and pump tanks and permitted system.
Diagram Not to Scale
Dry Well PL
-o
0
load — aved P nd osed�Nco Prop IP
NAG S nd
e itted Proposed
11 2S'mi from
Existing Well 0 84 any ucture
foo, Proposed
IP
Septic.
8,42' 0 And
0 Pump
Tanks
propos d
I'L � Repair ^� A�0
i
10,
i Q 50,
Proposed
System Area
Iron Pipe
food/dna Hill nr/�e N
IP
This permit is valid for a period of five years except that it may be revoked at any time if it is determined that there has been a material change in any fact or
circumstance upon which the permit is issued. Well location,installation,and protection must meet state regulations.The well shall be inspected and approved by Macon County
Public Health before It is put into use. The location of the well indicated by MCPH is to provide protection from possible sources of contamination. Flow volume(well yield)is NOT
guaranteed at any site by MCPH.
A WELLHEAD COMPLETION INSPECTION MUST BE APPROVED BEFORE FINAL POWER IS GRANTED OR THE WELL IS PLACED INTO
SERVICE. PLEASE SCHEDULE A WELLHEAD INSPECTION AFTER PUMP INSTALLATION. QUESTIONS?[phone]
Issue Date: 3127/2023 Charles Womack, REFIS 1300 _ Authorized State Agent